Implementation of an eHealth self-management care path for chronic somatic conditions

Full text

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Implementation of an eHealth self-management care path for chronic

somatic conditions

Y. Ciere

a,b

, R. van der Vaart

a,⇑

, A.E. van der Meulen-De Jong

c

, P.W.J. Maljaars

c

, A.R. van Buul

d

,

J.G. Koopmans

c

, J.B. Snoeck-Stroband

b

, N.H. Chavannes

e

, J.K. Sont

b

, A.W.M. Evers

a

a

Unit of Health, Medical and Neuropsychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, the Netherlands

bDepartment of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands c

Department of Gastroenterology and Hepatology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands

d

Department of Pulmonology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands

e

Department of Public Health and Primary Care, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands

a r t i c l e i n f o

Article history:

Received 20 December 2018 Revised 27 March 2019 Available online 13 May 2019

Keywords:

eHealth self-management

Online cognitive behavioural therapy iCBT

Screening Implementation

a b s t r a c t

Introduction:Self-management support for people with chronic somatic conditions can enhance clinical outcomes and patients’ quality of life. Implementing self-management support via eHealth could increase its availability and use. However, the implementation process in a hospital setting has not been studied yet. Therefore, we studied factors influencing the implementation process of an eHealth self-management support care path in two departments of an academic hospital.

Methods:Semi-structured interviews with healthcare professionals (HCPs) were conducted. Questions were based on the Consolidated Framework for Implementation Research, covering five domains: the implemented intervention, individual characteristics of the users (HCPs and patients), the inner setting of implementation (the two clinics), the outer setting (the hospital and broader health care organization), and the implementation process.

Results: In all five domains important facilitators and barriers were found and summarized, using sub-themes and citations to illustrate each theme.

Conclusion:This study provides practical implications for the implementation of eHealth self-management interventions in hospitals. Main findings suggest that both the content of an intervention and the process of implementation needs to be tailored to the end-users, using co-design. Moreover, suc-cessful implementation can be reached if there is readiness to adopt a new way of working, and if sus-tainability of this adoption is warranted throughout an organization, both on executive and management levels.

Ó2019 The Authors. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/ 4.0/).

Introduction

Evidence shows that self-management support using cognitive behavioral therapy (CBT), has positive effects on both psychologi-cal (e.g., depression and anxiety) and physipsychologi-cal (e.g., pain, fatigue) outcomes in patients with a chronic somatic condition.1–4CBT is

the most widely used therapeutical technique to support people in the adjustment to their chronic condition and to treat prevalent co-morbid psychological disorders and has been shown to opti-mize treatment outcomes and positively impacts patients’ quality of life.2,4However, people with one or more chronic somatic

con-ditions often face challenges in accessing self-management sup-port. On the one hand, health care providers in mental health care do not always have sufficient knowledge about chronic somatic conditions and their interaction with psychosocial func-tioning. On the other hand, within the medical setting, medical professionals do not always signal signs of psychosocial burden and self-management support is scarcely available. Furthermore, patients with a chronic somatic condition may feel resistance to self-management support or have physical limitations that make travelling to a therapist difficult. Innovations to improve the acces-sibility of self-management support for patients with a chronic medical condition are therefore needed.

A promising way to improve the accessibility of self-management support for people with a chronic somatic condition

https://doi.org/10.1016/j.ceh.2019.04.001

2588-9141/Ó2019 The Authors. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

⇑ Corresponding author.

E-mail address:r.vandervaart@fsw.leidenuniv.nl(R. van der Vaart).

Contents lists available atScienceDirect

Clinical eHealth

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is by delivering treatment via the internet, using eHealth applica-tions. For patients this could have the advantage that treatment can be accessed from home and at any time of the day. Also, the perceived stigma of seeking self-management support may be lower.5For therapists, internet-based CBT (iCBT) may require less

time investment than regular CBT and allow for more scheduling flexibility. Over the past decade, a growing number of studies have reported the use of iCBT in patients with a chronic somatic condi-tion.6,7These studies show consistent positive effects of iCBT on

disease-related outcomes such as physical symptoms (e.g., pain), psychological outcomes (e.g. anxiety and depression), and disease-specific quality of life. Notably, effects of iCBT seem to be comparable with the effect of face-to-face CBT, provided that treat-ment is guided by a therapist.6–8Furthermore, there is some

evi-dence suggesting that iCBT is more effective when combined with a screening for psychological distress.6

Although empirical support for the benefits of iCBT for patient with a chronic somatic condition is mounting, implementation in clinical care falls behind. The Consolidated Framework for Imple-mentation Research (CFIR) suggests that barriers and facilitators for the implementation of health services can be identified on five levels: 1) the intervention, 2) the individuals involved in imple-mentation (e.g., healthcare providers), 3) the inner setting (e.g. the organization or units within the organization), 4) the outer set-ting (e.g., the organization or larger healthcare system), and 5) the implementation process.9 With regard to the implementation of eHealth in general, previous literature reviews have indeed described facilitators and barriers on all these levels.10–12In

partic-ular, the need for supportive legislation and recognized standards, fit with the current workflow, the extent to which eHealth is per-ceived to have a positive impact on the quality of care, and finan-cial resources available for eHealth have been identified as key factors influencing implementation success.10,12

A hospital may present a particularly challenging context for the implementation of screening and iCBT. That is, the integration of such a health service in clinical care requires a complex change process at the level of patients and healthcare providers, but also at the level of department culture and workflow, hospital infrastruc-ture (e.g., ICT) and policy. A recent study indeed found that in hos-pitals in the Netherlands, the adoption of eHealth often stagnates after the initial phase of interest in or commitment to eHealth.13

To our knowledge, the specific factors influencing the implementa-tion of iCBT in a hospital setting have not yet been described. More insight into these factors may, however, promote the integration of iCBT in clinical practice. In this paper, we describe the pilot imple-mentation of an eHealth self-management support care path, con-sisting of a screening for psychological distress and guided iCBT. Implementation is realized at two outpatient clinics of an academic hospital in the Netherlands, the Department of Gastroenterology and the Department of Pulmonology. Qualitative interviews with healthcare providers were used to identify facilitators and barriers influencing implementation success.

Methods

Self-management eHealth care path

The eHealth self-management support care path was imple-mented at the outpatient clinics of the Departments of Pul-monology and Gastroenterology of Leiden University Medical Center, the Netherlands, between March 2017 and October 2018. Because time and resources were limited, the care path was ini-tially only implemented among patients with inflammatory bowel disease (Department of Gastroenterology) and patients with obstructive lung diseases (Department of Pulmonology). In a later

stage, also patients with other lung conditions were included in the care path.

The implementation of the eHealth care path was coordinated by a project team which consisted of the treating psychologist (YC), supervisor and certified clinical psychologist (AE), implemen-tation leaders from the two outpatient clinics (AvdM, JK, AvB), an assistant and associate professor (RvdV and JS) and two professors (AE and NC) with substantial expertise in eHealth. During the plan-ning phase (November 2016 – March 2018), the project team developed working procedures in close collaboration with health-care professionals from the outpatient clinics. . .During the train-ing phase (March 2017 – Sept. 2017), meettrain-ings were held with healthcare professionals and supportive staff from both depart-ments to familiarize them with the goal and the working proce-dures of the care path. Also during this phase, working procedures were tested and regularly evaluated and optimized based on feedback from healthcare professionals and the project team. Finally, in the execution and evaluation phase (Sept. 2017 – Nov. 2018) the care path was implemented and evaluated. If nec-essary, minor adjustments to the working procedures were made during this phase. Throughout the whole project, healthcare pro-fessionals were reminded of, and updated about the implementa-tion via e-mail and in team meetings at least every 4–6 weeks.

The implemented eHealth self-management support care path consisted of two steps, as depicted inFig. 1. In step one, patients were screened for psychological distress using an online tool assessing the PHQ-914and GAD-7.15At both departments the use

of the screening tool was slightly different. At the Department of Gastroenterology, patients were first inquired about distress symp-toms either during a regular medical consultation or via the eHealth application ‘MyIBDCoach’. This application was developed with a structured iterative process between patients, dietitians, IBD nurse-specialists, and gastroenterologists. The Leiden Univer-sity Medical Center (LUMC), and the Dutch IBD patient organiza-tion (CCUVN) (https://www.mijnibdcoach.nl) were actively involved. The application was already used as part of regular care at the start of this project.16If there was any sign of possible

dis-tress symptoms, patients were invited to complete the screening measures on paper. At the Department of Pulmonology, visiting patients were initially invited by email for screening via the eHealth application ‘PatientCoach’, developed and hosted by LUMC (www.patientcoach.lumc.nl). However, because this resulted in very few responses, patients were eventually directly referred to the care path by their medical specialist, after which screening was performed via ‘PatientCoach’ or on paper. After screening or referral, patients who scored above the cut-off (PHQ-9 and/or GAD-710) were called by a medical psychologist to check moti-vation and suitability for eHealth self-management support. Patients with highly severe distress symptoms (PHQ-9 and/or GAD-7 > 20) were called as well, and advised to contact their gen-eral practitioner for further evaluation and referral.

In step two, patients who were motivated and suitable to receive eHealth self-management support were invited for an intake consult with a medical psychologist. This consult included an assessment of symptoms and treatment needs, as well as a dis-cussion about treatment options. If patients were still motivated to receive treatment after the intake consult, they started with online orblended CBT using the eHealth application ‘E-coach’.17,18 This

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In the case of blended therapy, online treatment was comple-mented, with an addition of (max) five face-to-face sessions at the outpatient clinic. Patients who were unwilling or unable to receive online or blended self-management support, for instance due to a lack of computer skills or presence of psychiatric co-morbid conditions, were referred to a psychological healthcare provider outside of the hospital.

At the Department of Gastroenterology, 104 patients were screened or referred to the eHealth self-management support care path. Of the 82 positively screened or referred patients, 54 were seen for an intake consultation. After the intake consultation, 30 patients started with online or blended CBT, 13 patients did not receive CBT because they no longer needed treatment, and 11 patients were referred to another healthcare provider for a differ-ent type of psychological care. At the Departmdiffer-ent of Pulmonology, 110 patients were either screened or directly referred to the eHealth care path. Of the 54 positively screened or referred patients, 25 patients were seen for an intake consultation. After the intake consultation, 12 patients started online or blended CBT, 10 patients were referred to a healthcare provider outside of the hospital for a different type of psychological care, and 3 patients no longer needed treatment.

Study design and participants

Semi-structured interviews with healthcare professionals from both outpatient clinics were conducted between May and Septem-ber 2018 to identify factors influencing the implementation of the psychological eHealth care path. A convenience sample of health-care professionals at the two departments was invited. All invited healthcare professionals agreed with participation. In total 10 healthcare professionals were interviewed, which were equally

distributed over the two outpatient clinics. The majority of inter-viewees was female (80%). Four interinter-viewees were medical spe-cialists (40%), three were specialist nurses (30%), two were residents (20%) and one was medical doctor and researcher (10%). In Appendix A an overview of the characteristics of the inter-viewed healthcare professionals is shown.

Procedure

Healthcare professionals (HCPs) were interviewed once during the final phase of the project by the first author (YC). An interview guide was used covering the five domains of the Consolidated Framework for Implementation Research (CFIR)9 (see Appendix

B). The interviewee was first invited to reflect about his or her experience with the implementation of the care path, after which further questions were prompted to ensure that facilitators and barriers regarding all domains of the CFIR were covered, namely (1) the implemented intervention, (2) the individual characteristics of the users (HCPs and patients), (3) the inner setting of implemen-tation (the two clinics), (4) the outer setting (the hospital and broader health care organization), and, (5) the implementation process. Interviews took place in the hospital and lasted generally half an hour. The interviews were audio-taped and transcribed verbatim.

Analysis

Analysis of the interviews took place in two steps. First, two authors (YC and RV) independently categorized fragments within the interviews in the five CFIR domains. Discrepancies were discussed by the two researchers until consensus was reached. Second, an inductive approach was used to identify themes within

Step 1: Screening

Brief screening for psychological distress

Medical specialist inquires about presence of distress in past

weeks (gastroenterology department only)

Step 2: Psychological treatment

No – mild distress

PHQ-9 and GAD-7

<10

Moderate – severe

distress

PHQ-9 and/or GAD-7

≥10, <20

Highly severe distress

PHQ-9 ≥ 20,

and/or GAD-7 ≥ 14

Standard medical care

Intake with medical

psychologist

Referral via general

practitioner

Online or blended CBT

using

E-coach

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the five main domains. One of the authors (YC) created a coding scheme using a subset of three interviews. This coding scheme was checked by the second author (RV) before it was used to code the other interviews. Any new themes that emerged while coding the other interviews were added to the coding scheme.

Results

Facilitators and barriers as mentioned in each of the five CFIR domains are summarized below.

The intervention

Characteristics of the intervention that influenced implementa-tion of the eHealth psychological care path are presented inTable 1. Many HCPs experienced the situation after implementation of the care path as an improvement. They perceived it as anenhancement of carethat they could now directly refer patients to a psychologist with knowledge of the chronic condition. Another factor that was frequently mentioned was that the self-management support within the care path was easilyaccessible, as patients could meet their psychologist at the outpatient clinic as well as online. Also, some HCPs found it helpful that treatment could beflexibly adapted

to the needs of an individual patient (e.g., blended treatment could be offered). Implementation was further strengthened when HCPs receivedpositive feedback from patients, which motivated them to continue to include patients in the care path. Also, the medical spe-cialists perceived aminimal burdenof the care path in their regular work flow. Nevertheless, an important facilitating factor was the

involvementof a medical specialist to some extent, in order to moti-vate patients to participate in screening and to consider psycholog-ical care. Finally, it was seen as a facilitating condition that the psychologist was available forinterdisciplinary collaboration, which made the care path an integrated part of outpatient treatment.

Despite their positive experiences with the care path, HCPs also indicated that there was still room for improvement. That is, a number of HCPs reported that the care pathdid not meet the needs and preferences of every patientin their patient population and that the care path was currently onlysuitable for a subset of patients, which both could be barriers to optimal implementation. HCPs for instance encountered the barrier that some patients were unable to use a computer or preferred face-to-face treatment. Also, patients with chronic or severe psychological complaints still had to be referred to external psychological health care, because short-term online or blended treatment did not sufficiently meet their needs. Although the easy accessibility of the care path was seen as a facilitating factor, some HCPs found it a barrier that the care path was presented asoptional. A HCP from the Department of Pulmonology for instance explained that many patients refused psychological care and thatlabelling the care path as ‘psychological care’, as was done by some HCPs, did not help in this regard. Some healthcare professionals further reported thelimited integrationof the eHealth applications with each other, as well as with existing ICT systems in the hospital (e.g., the electronic patient file) as a barrier to implementation. Finally, one HCP mentioned the fact that one of the screening tools used a complex log-in procedure, which reduceduser-friendliness.

Individual characteristics of healthcare providers and patients

Table 2reports characteristics of patients and healthcare provi-ders that influenced implementation (note: patient characteristics were reported by HCPs and not by patients themselves). An impor-tant facilitating factor was that many HCPsbelievedin the added value of offering self-management support as part of treatment in their clinic and as an improvement of their current quality of care. Other facilitating factors were that a HCP hadattention for a patient’s psychosocial functioning during clinical encounters and

Table 1

Characteristics of the intervention that influenced implementation.

Code Example quote

Facilitators

Enhancement of care For me it was very valuable, because I really had something to offer to patients. Now it’s back to. . . well if I signal any problems I can tell the patient to go to their GP, but they often don’t do that. (R2) Accessibility I think iCBT can be of added value for many people, especially because this is such a large tertiary referral center. People come from far and wide and may therefore be more likely to participate online. (R3)

Flexibility of the intervention I like that it can be adapted to the needs of the care recipient. That it is not a fixed program that people have to follow. (R4)

Positive experience of patients What I heard back was positive, sometimes it really offered a breakthrough for people, like. . .”now I know what I struggled with all these years. . .now I know what to do”. (R3)

Minimal burden on medical specialists The questionnaire was easy, as a screening tool, because it didn’t cost me much time. You only had to ask if someone felt up to it, and then people could do it on their own without any interference from us. (R3)

Involvement of medical specialist With screening, our experience was, as we already knew, that a little push from the pulmonologist is important. That patients hear ‘‘oh, my pulmonologist finds it important that I do this” (R10) Room for interdisciplinary collaboration It was easy to get in touch with you. I believe that is very useful, that you. . .like recently with this

patient, that you can discuss what we are going to say to this person. (R7)

Barriers

Insufficient match with needs/preferences of target group Well eHealth, I find it difficult, because there are. . .[. . .] there is a large group here that is less educated and that does not use a computer very often. (R9)

eHealth care path only suitable for subset of patients I think it is unfortunate for these patients that they still had to be referred. Of course, this was now the case because it wasn’t possible within the boundaries of this project. But ideally, these patients should be able to receive treatment here. (R4)

Care path is optional As it’s on a voluntary basis now, many people say ‘‘I don’t need it” or ‘‘I don’t want it” or ‘‘I don’t want it because there is nothing going on with me”. (R9)

Label psychological care In the clinic we notice that people still perceive a barrier. If you keep calling it ‘psychological care’ it won’t facilitate implementation. (R1)

Limited integration of IT systems [. . .] it’s a separate program. It feels a bit outside of [name electronic patient system] and outside of [name hospital]. (R2)

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had enoughself-efficacy and skillsto actually discuss this with a patient. Notably, a HCPs motivation to include patients in the care path seemed to increase when the person gainedpositive experi-encewith the care path, for instance when he or she noticed the effect of self-management support on a patient.

The high workloadand a lack of timeto discuss psychosocial functioning with a patient during a consultation were most often mentioned as barriers to implementation. Many HCPs reported that they did not always mention the care path, because the con-sultation time was limited and other issues had to be prioritized. In addition, some HCPs admitted that their focuswas currently mainly on somatic functioning or that the care path was simply

not on top of their mind.One HCP mentioned that she feared bring-ing up psychosocial functionbring-ing because of stigma. Some HCPs included so few patients in the care path that they gained little tono experience with the care path, which in turn influenced their motivation to be involved in the implementation. In addition, a number of HCPs from the Department of Pulmonology mentioned that they encounteredresistance towards self-management support

among their patients, when introducing the care path. Other patientsdid not feel the need for self-management,even when their HCP believed that this would be beneficial.

Inner setting (outpatient clinics)

The two departments, with each their own unique organiza-tional structure, represented the inner setting in this project (see Table 3). It should be noted there were organizational changes at the Department of Pulmonology during the project. In the Depart-ment of Gastroenterology, only part of the departDepart-ment staff was involved in this project due to the focus on inflammatory bowel disease (IBD). A facilitating factor in both departments was that, according to HCPs, the departmenttreated patients who may benefit

from self-management support. That is, HCPs from both depart-ments recognized that psychosocial functioning interacted with the physical functioning and treatment behavior of patients in

their outpatient clinic. Especially at the Department of Gastroen-terology, there was a shared vision regarding the need for self-management support, which was also discussed among the treat-ment team in interdisciplinary meetings. At this department, employees (e.g., specialist nurses) were grantedtime and resources

to work on healthcare innovations related to the theme of patient-centered care. Also, supervisors were actively involved in the implementation, for instance by reminding HCPs of the care path during the interdisciplinary meeting. As a result, the care path became more and more an integral part of treatment at this department.

In contrast, at the Department of Pulmonology there was not a completely shared vision regarding the benefit of self-management support and embedding iCBT into their daily practice. Psychosocial problems were less frequently discussed in team meetings or dur-ing supervision and in the organization of care there was little room for interdisciplinary collaboration (e.g., no interdisciplinary meeting). This was partly due to the fact that the patient popula-tion in the clinic was verymixed. Another important barrier was that the project’s focus on chronic and obstructive lung diseases no longer aligned with the new focus of the department. As a result, the project did not fit well within the current organization of the clinic and HCPs had few time and resources available to work on the implementation of the care path. These organizational changes might also explain why many HCPs from the Department of Pulmonology had difficulty prioritizing the project in their daily work (see ‘Patients and healthcare providers’). Lastly, some HCPs mentioned the individualistic culture in the department which, according to the HCPs, hindered many research and healthcare innovation projects within the department.

Outer setting (hospital and broader context)

The outer setting in this project was the academic hospital as well as the broader regional and national healthcare organization. Characteristics of the outer setting that influenced implementation

Table 2

Characteristics of health care providers (HCP) and patients (P) that influenced implementation.

Code Example quote

Facilitators

Belief in added value (HCP) With some patients you always keep this nagging feeling that you can’t do enough, and that’s taken away. And maybe the quality of the treatment is also enhanced, because you also treat that element. (R10)

Focus on psychosocial functioning (HCP) I think, when it comes to people with chronic conditions, you are taking the easy way out if you just check the mucosa. I think you really need to deal with it. (R7)

Self-efficacy/skills (HCP) That was actually quite easy [. . .] so I posed a lot of questions, and then at some point I also asked: do you sometimes struggle with your symptoms? Or, if a patient would mention certain stressors for example, then I could offer them the care path (R2)

Positive experience (HCP) Especially since I encountered patients with certain problems in my office more often. . .eh you notice that they really struggle with their disease and how to cope with it in daily life. You do notice that that’s quite common and that it. . .ehm, yes that it’s good that we address that this way. (R5)

Knowledge (HCP) For me it is absolutely essential that the psychologist knows what the disease entails. So, for me that’s a prerequisite. (R8)

Barriers

High workload/lack of time (HCP) And of course there’s not much time available. Fifteen minutes per patient, including the administration and everything. (R2)

Current focus on somatic care (HCP) I do think, as a doctor we are too much focused on the somatic symptoms. And we. . .I only start thinking about other problems if a patient brings it up himself. We usually don’t flag it. (R10)

Not on top of the mind (HCP) I think the problem often is the referral, or addressing it during consult. I don’t think about that enough (R6) Fear of bringing up stigma (HCP) What I found is that those questionnaires can be quite heavy, it’s all about depression of course. I can imagine that

scares patients off. (R5)

Limited experience with care path (HCP) There were actually very few people who gave me feedback on how they liked it. Because I didn’t ask, or because they didn’t brought it up. (R3)

Resistance towards self-management support (P)

People don’t want to go to a psychologist. At least not in the Netherlands. If you would do this in America it might be different, because everybody sees a psychologist over there, but that’s not the case with us. (R1)

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are presented inTable 4. As facilitating factors, HCPs mentioned that the hospital providesroom for healthcare innovationprojects such as this one and that the projectaligned well with hospital pri-orities. Indeed, this pilot project was supported and funded by the hospital’s eHealth steering committee and the implementation of eHealth is one of the focus areas in the organization’s policy plan. One of the barriers that HCPs encountered during this project was that there is generally alack of collaboration between depart-ments within the hospital. Although HCPs knew that other depart-ments in the hospital were working on implementing eHealth and self-management support, the limited visibility of these initia-tives prevented the exchange of information and collaboration. In the Department of Pulmonology specifically, another barrier was that HCPs also built their own referral network outside of the hos-pital. Theavailability ofthisalternative caresometimes competed with the care that was provided in the eHealth care path. Finally, HCPs mentioned organizational barriers with regard to the mainte-nance of implementation after the pilot phase. Although the IBD team was highly motivated to maintain implementation, a barrier was that this required department resources to employ a psychol-ogist as part of the treatment team. They perceived it as a limiting condition thatpsychologists are not centrally available within the

hospitaland that thehospital board does not give departments sup-port or incentivesto employ a medical psychologist.

The implementation process

Characteristics of the implementation process that either facil-itated or hindered implementation are presented in Table 5. A number of HCPs reported that they were satisfied with the extent to which they were engaged andinformedduring the project, for instance through updates in team meetings. Some HCP also men-tioned that theinvolvement of the implementation leader in their department had been a promoting factor. However, the extent to which HCP truly prioritized the implementation did seem to depend on whether the implementation leader was someone with formal influence on the group (e.g., a supervisor). Other facilitating factors were that there was ample ofroom to reflect on and evaluate

the working procedure, and that this procedure could beflexibly adaptedwhen needed. For instance, HCPs from the Department of Pulmonology appreciated that there was room for trial and error to come to the most optimal screening procedure in their department.

Table 3

Characteristics of the inner setting (clinics) that influenced implementation.

Code Example quote

Facilitators

Department treats patients that may benefit from psychological care

Still, I had the idea that it could contribute a lot. Because in the treatment of asthma patients there is often a psychological component. (R1)

Team has shared vision regarding added value of psychological care

We have a team that is really open to go for it, for this psychological care path. [. . .] People should want it and see the added value of it, I think that is really essential for the success of this project. (R5)

Room for interdisciplinary consultation What really facilitated was the weekly feedback during our interdisciplinary meeting, which made it come more alive to everybody. (R5)

Availability of time and resources We have a lot of nurse specialists and that means that you have the manpower to organize things very well. (R7) Active involvement of supervisors Supervisors paid a lot of attention to it, like ‘‘don’t forget to let people fill out the (screening) questionnaires”. It was

really pushed into our system. (R3)

Barriers

No shared vision regarding psychological care within department

Of course we don’t have any psychological care at this moment, it is just not something that people are familiar with and that they easily see the added value of. (R1)

Insufficient fit with existing care So basically we were not ready yet and the approach didn’t fit within our department. I think that is a difficulty. . .not tailored enough. (R8)

Project does not align with department priorities

I sometimes got the feeling that the project was a little neglected (R2)

Lack of resources I think it would have been different if we had more manpower. I mean, now it has to be done next to other tasks. (R1) Individualistic culture The doctors here are quite individualistic. All on their own island so to say. And that’s difficult when you want to get

things done. (R9)

Mixed patient population Well I think that’s a barrier. . .for instance if I compare it with the Department of Gastroenterology, they have huge outpatient clinics with inflammatory bowel disease patients. And we have a much more mixed patient

population. (R1)

Table 4

Characteristics of the outer setting that influenced implementation.

Code Example quote

Facilitators

Room for innovation I think an academic hospital is really prepared to give these kinds of projects a chance. (R5) Alignment with hospital priorities I haven’t worked here for a long time, but I did notice that inflammatory bowel diseases are a major

priority in this hospital. (R3)

Barriers

Lack of collaboration between departments within the hospital It seems that we’re re-inventing the wheel. There are lots of different projects on different levels of this hospital, or in different departments, that you don’t know of because the organization is so large. (R5)

Availability of alternative care outside of the hospital I often refer people to a physical therapist and that is often quite effective. (R6)

Limited availability of medical psychologists within the hospital Ideally, the hospital would have the vision that medical psychologists should always be part of the treatment team. (R4)

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A barrier in the implementation process was that both depart-ments were not familiar with offering self-management support by a psychologist. Also, despite the large attention for eHealth in the hospital, the implementation of eHealth care was still in its infancy. Hence, this implementation felt likepioneeringfor some HCPs. Another limiting factor in this regard was the small scale

and short timeline of this project. Although the small scale did allow for flexibility, the care path may have received wider support within the departments if it had been implemented in a larger group of patients. With regard to information provision, a barrier was the changing composition of the treatment team (e.g. resi-dents in the Department of Gastroenterology changed every three months). Hence, it appeared that more frequent and continuous information provision was needed. Finally, an important barrier for maintenance of implementation was the lack of sustainable embeddingof the care path in the organizational structure, partic-ular financing a medical psychologist.

Discussion

In this paper, we aimed to provide insight into factors influenc-ing the pilot implementation of an eHealth self-management sup-port care path for patients with chronic somatic conditions in two outpatient clinics of an academic hospital. Interviews with health-care professionals revealed essential factors influencing implemen-tation on the level of the intervention, individuals involved in the intervention, the inner and outer setting, and the implementation process. These findings underscore the complexity of eHealth implementation, and may partly explain why eHealth implementa-tion in hospitals can stagnate after the first stage of interest or commitment.13,19

Concerning the major facilitating factors for implementation as mentioned by health care professionals, we found that the treat-ment team needs to have a shared vision regarding the benefit of embedding eHealth self-management support into their daily practice. The care path in this project was seen to offer a clear advantage compared to the pre-implementation situation, as self-management support became more accessible to patients and healthcare providers were now able to collaborate with the treat-ing psychologist. As a result, healthcare providers believed that they could provide better quality of care. Indeed, the perceived impact of eHealth on the quality of healthcare is one of the most often reported success factors for eHealth implementation and technology implementation in general.10,20Additionally, the care path only became a truly integrated part of treatment at a

depart-ment if the treatdepart-ment team had a shared motivation for change, supervisors were engaged, and if the care path was largely compat-ible with the existing workflow and team values. This finding con-curs with results of previous studies that have shown that the implementation climate in an organization is a key factor influenc-ing the implementation of eHealth.12 In future implementation

projects, it is therefore important to foster stakeholders engage-ment, as well as a favorable implementation climate and sufficient implementation readiness within an organization.

Regarding the key barriers affecting implementation in this pro-ject, the care path did not yet meet the specific needs and prefer-ences of all patients within the target group. More specifically, not all patients were able or willing to use eHealth and a substan-tial number of patients needed to be referred for other or more intensive treatment. Notably, the needs and preferences of patients appeared to differ among the two outpatient clinics, which is in line with an earlier study showing that expectations and needs regarding eHealth for chronic disease self-management differed across diagnosis groups.21Additionally, this study was conducted

in an academic setting, in which both the medical and psychosocial needs of patients are typically more complex. It appears that suc-cessful implementation of eHealth self-management support in an academic hospital setting requires eHealth applications that are highly tailored to the needs of specific patient groups, as well as the option to combine eHealth self-management support with more intensive face-to-face treatment. Other important barriers as perceived by the health care professionals included the general high perceived workload of clinicians and difficulty fitting the care path into the existing workflow, given the limited availability of time and resources. Workload has indeed been frequently reported as a factor that limits integration of eHealth into the workflow.10 Although we found that the extent to which implementation is pri-oritized and encouraged by supervisors is also of influence, which again stresses the need for implementation readiness and support among all levels within an organization. With regard to the contin-uation of implementation, costs of the intervention (in particular costs for employing a psychologist) were a major barrier. This also represents the importance of vision and broader support within an organization. Therefore, in future projects it is advisable to guaran-tee conditions for sustainable embedding and maintenance on an organizational level before the start of a pilot.

This study provided relevant insights into how to enhance implementation strategies of psychological care in hospitals via eHealth. Nevertheless, some limitations should be taken into account. First of all, the scope of the current overview is narrowed

Table 5

Characteristics of the implementation process that influenced implementation.

Code Example quote

Facilitators

Information provision I believe that you gave a clear explanation during our interdisciplinary meeting, as well as a lesson about what your work involves. This made the project come to life a bit more. (R5)

Involvement key stakeholders/project leaders I find that you, as well as [name key stakeholder], took the lead very well. And again, it is super important that people are really engaged and I think that [key stakeholder] really was engaged. (R5) Room for reflection and evaluation That you were really enthusiastic and gave quick feedback, like there are no questionnaires coming

in, how come? And then we realized that we didn’t ask anybody. (R7)

Flexible strategy Later on, we agreed that we could refer all patients to you, not only the patients who were already in the [existing eHealth] care path. After that I felt it went more smoothly. (R2)

Barriers

Pioneering We really started from scratch. Of course, first we had this barrier with [name eHealth tool] and then with screening. Naturally, in the future you could skip these steps because now we know what works and what doesn’t. (R2)

Small scale I would try to come up with a way to reach more people. (R7)

Need for more (continuous) information provision. The team of residents is constantly changing [. . .] if we discuss something only once during the interdisciplinary meeting, it has limited value because after three months there will already be new people. (R7)

(8)

by only interviewing health care professionals. To come to a com-plete overview of implementation facilitators and barriers, other stakeholders such as patients, psychologists and managers would be relevant to address as well. Second, it should be taken into account that this study represents the evaluation of a small scale project, including only two outpatients clinics within a large aca-demic hospital. This small scale implementation has probably had its own influence on the perceived facilitators and barriers. For instance, it could have enhanced the communication between the project team and the clinics, increasing HCPs motivation to participate, but on the other hand it was more difficult to gain broad support and attention from the hospital board. If the project could have been performed on a larger scale, results from this study might be different.

All in all, this project provides multiple implications for the implementation of eHealth applications in hospitals. What we can conclude is that both the intervention and the process of implemen-tation needs to be tailored to the end-users. That means, co-design of the online therapy with patients and care providers, but also co-design of the implementation strategy with care providers and man-agers.22 Subsequently, successful implementation can only be

reached if there is readiness to adopt a new way of working, and if sustainability of this adoption is warranted throughout an organiza-tion, both on executive and management levels.

Acknowledgements

We thank all the health care providers for their participation in this study. We thank the staff of both departments for their sup-port in the implementation process.

Funding

This project was funded by the eHealth Steering Committee of Leiden University Medical Center. This sponsor had no role in the study design, collection, analysis and interpretation of data, in the writing of the report; and in the decision to submit the paper for publication.

Declaration of interest

None.

Appendix A Characteristics of participants

Respondent Department Gender Position

1 Pulmonology Female Medical specialist 2 Pulmonology Female Medical doctor/

researcher 3 Gastroenterology Female Resident 4 Gastroenterology Female Specialist nurse 5 Gastroenterology Female Specialist nurse in

training

6 Pulmonology Male Resident

7 Gastroenterology Male Medical specialist 8 Gastroenterology Female Medical specialist 9 Pulmonology Female Specialist nurse 10 Pulmonology Female Medical specialist

Appendix B Interview guide

Facilitating factors and barriers in the implementation of an eHealth self-management support care path

First, Could you tell me about your general experience with the implementation of the eHealth self-management support care path. I’m interested in anything that comes to your mind in rela-tion to the integrarela-tion and use of the care path in your department. For instance, the patient inflow, the impact on your work flow, the outcomes of the care path, whether everything went according to plan, etcetera.

Can you tell me about your general experience with the imple-mentation of this care path?

Now I would like to talk with you about the barriers and facil-itating factors that you have encountered during the implementa-tion of this care path. We will discuss barriers and facilitating factors on five levels: 1) the intervention, 2) your work as a health-care provider, 3) your department, 4) the hospital, and 5) the implementation process.

Intervention

Which aspects of the intervention (i.e., the design of the care path and the eHealth applications) may have facilitated or hin-dered the implementation of the care path?

Note to interviewer: explore both facilitating factors and barriers.

Probing topics:

- Intervention source - Evidence strength

- Relative advantage of eHealth and self-management support - Degree to which care path can be adapted to department needs - Ability to test on a small scale

- Perceived difficulty/complexity of the intervention - Presentation of the intervention

- Costs of the intervention

Individual characteristics

Which aspects considering you as a healthcare professional may have facilitated or hindered the implementation of the care path? For example, how did you feel about this care path, and how did this change over the course of this project? What knowledge or skills did you need as a healthcare provi-der to be able to integrate this care path into your work flow?

Probing topics:

- Beliefs about the care path - Knowledge and skills - Motivation

- Self-efficacy

- Other personal characteristics (e.g., level of experience, gender)

Inner setting

Which circumstances within your department have facilitated or hindered the implementation of this care path?

Probing topics:

(9)

o Need for innovation, alignment with department goals, rel-ative priority for the care path, incentives, clarity of objec-tives, role of team leaders

- Readiness for implementation

o Team leader involvement, available resources (time, money), available information

Outer setting

Which circumstances within the hospital, or outside of the hos-pital, have facilitated or hindered the implementation of this care path?

Probing topics:

- Patient needs and resources

- Network/collaboration, within and outside of the organization - Pressure from within and outside of the organization

- Policy and incentives, inside and outside of the organization

Implementation process

How have you experienced the process of implementing this care path? What went well, and what would you differently next time?

Probing topics:

- Implementation plan, level of involvement - Engagement of health care professionals - Did everything go according to plan? - Room for reflection and evaluation

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Figure

Updating...

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